Rosie's Southside Animal Shelter Adoption Application
Please note: this form alone does not approve you to finalize an adoption. The purpose of this form is to then schedule an interview with staff and a time to meet with the animals.
**All applicants must reside in the state of Indiana
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Today's Date *
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Time
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Time
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I am interested in adopting a... 
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If you are applying for a specific animal, list the name(s) of the animal(s) you wish to adopt:
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Why do you want this pet?
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Full legal name
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Date of birth
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Full legal name of any co-applicant (spouses, partners. roommates)
Date of birth of co-applicant
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Email address
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Phone number
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Preferred method of contact
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Required
Street Address
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City- state- zip
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Do you own, rent, or live with family?
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If you selected rent or live with family, please provide the name and number of either the company/landlord, or the family member with whom you reside
Are there any children in your home? If yes, how many and how old are they?
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Employer, job title, and amount of time at job (months, years)
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Please list ALL pets you have had in the past 5 years. Please list name, age, breed and where they are now. If this portion is not filled out in full, your application will NOT be processed. 
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Have all of the pets in your home in the past 5 years been spayed or neutered?
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Have you had any pets pass away in the past 5 years? If yes, please list the cause of death and the vet clinic they were last seen at. 
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Are all of your current pets up to date on vaccinations?
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Are all of your current pets up to date on heartworm prevention?
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Current or past veterinary clinic name & the owner's name on file
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Where will this pet be kept? Check all that apply. 
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Is your yard fenced? *
Do you plan to declaw (cats only)?
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Have you ever adopted from us before? If so, when did you adopt? Where is the pet now?
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Have you ever given away or surrendered an animal? When and why?
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Are you financially prepared to deal with the cost of both routine (vaccinations, annual exams, dentals) and emergency care? 
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Please list 3 references. Include their name, relationship to you, and a phone number or email address we can use to contact them.
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Please mark any days of the week that you would be available during our business hours (12-5 Mon- Friday, 12-4 Saturday-Sunday). We will use this information to schedule your appointment should your application be approved. 
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Required
I acknowledge that Rosie's Southside Animal Shelter is a private organization and can choose to deny my application for any reason that they see fit. I also understand that completing this form does not result in my approval for adoption. 
Please type name in lieu of a signature. 
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